A nurse enters a client's room and finds the client experiencing a seizure on the floor. Which of the following actions should the nurse take?

• Urticaria: Present in latex allergy, as hypersensitivity reactions to latex can cause pruritic hives due to histamine release.
• Hypercapnia: Present in malignant hyperthermia, as it results from uncontrolled skeletal muscle contractions leading to excessive carbon dioxide production.
• Wheezes: Present in latex allergy due to bronchoconstriction and airway hypersensitivity, which can lead to respiratory distress.
• Muscle rigidity: Present in malignant hyperthermia, as sustained muscle contractions occur due to excessive calcium release in skeletal muscles.
• Tachycardia: Present in both malignant hyperthermia and hypovolemic shock. Malignant hyperthermia causes tachycardia due to increased metabolic activity and hypercapnia, while hypovolemic shock results in tachycardia as a compensatory mechanism for reduced circulating volume.

A. Communicate advance directives status via the medical record and shift report. The nurse is responsible for ensuring that all members of the healthcare team are aware of the client’s advance directives. Documenting this information in the medical record and shift report helps guide care in accordance with the client’s wishes.
B. Provide the client with written information about advance directives. Clients have the right to receive information about advance directives, including living wills and do-not-resuscitate (DNR) orders. The nurse should provide educational materials to help the client make informed decisions.
C. Inform the client that an advance directive discontinues further care. An advance directive does not automatically discontinue all medical care. It provides instructions regarding specific interventions the client wishes to accept or decline, such as resuscitation, mechanical ventilation, or artificial nutrition. The nurse should clarify this to avoid misconceptions.
D. Instruct the client that an advance directive is a legal document and must be honored by care providers. Advance directives are legally binding documents that must be followed by healthcare providers. The nurse should reinforce that the client’s wishes, as stated in the directive, will be respected.
E. Document that the provider discussed do-not-resuscitate status with the client. Proper documentation is essential to ensure the client's preferences regarding resuscitation and end-of-life care are acknowledged and followed. The nurse should record discussions regarding advance directives in the medical record.
F. Initiate a power of attorney for health care document. The nurse does not have the authority to initiate a power of attorney for health care. The client must complete this legal document independently or with legal assistance, and it typically requires notarization or witness signatures. The nurse can provide information about it but cannot create or execute it on the client’s behalf.